Provider Demographics
NPI:1457682890
Name:LEUTHOLD, KATHARINE MARIE (ATC)
Entity Type:Individual
Prefix:
First Name:KATHARINE
Middle Name:MARIE
Last Name:LEUTHOLD
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 5TH AVE S APT H2
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006-3338
Mailing Address - Country:US
Mailing Address - Phone:712-470-5364
Mailing Address - Fax:605-688-5999
Practice Address - Street 1:SPE 150X
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57007-0001
Practice Address - Country:US
Practice Address - Phone:712-470-5364
Practice Address - Fax:605-688-5999
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-25
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD03082255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD2000000167OtherATHLETIC TRAINING